Naturopathy vs. patients: Patients lose

Over the weekend, there was a news story describing two cancer patients treated by naturopaths in New Zealand. Both died, one almost certainly unnecessarily, the other after enduring more suffering than she likely had to. These tragic cases and others reminded me of why it is so appalling that so many physicians are “integrating” naturopathy into “integrative medicine.” In reality, they are integrating quackery into medicine.

We write frequently about naturopathy here because, of all the dubious pseudoscientific medical “disciplines” out there, naturopathy (along with chiropractic) has achieved the most “respectability.” Indeed, as I like to point out in my own specialty (breast cancer), the Society for Integrative Oncology (SIO) even admits naturopaths as members. Indeed, the immediate past president of SIO is a naturopath (and, depressingly, faculty at my medical alma mater, the University of Michigan), as was the SIO president in 2014. So entrenched are naturopaths in SIO that they have been prominent co-authors on SIO clinical guidelines papers, like this set of breast cancer guidelines, with two naturopaths as co-authors, one as first author. Basically, in academia at least, naturopaths have certainly surpassed chiropractors in terms of seeming respectability, even though they promote alternative medical treatments that, as I pointed out two weeks ago, kill cancer patients dead through lack of effective treatment.
I was reminded of this unfortunate infiltration of naturopaths when I saw a story yesterday from, of all places, New Zealand, “Naturopathy under microscope after cancer sufferers speak from under shadow of death.” It tells the story of two cancer patients who relied on naturopaths for treatment and didn’t live to regret it, at least not long. Consider this to be a sequel to my post from two weeks ago, only focusing on naturopaths.

An almost certainly preventable death

Naturopaths sell themselves to cancer patients as offering treatments that are “natural,” although I’ve always been puzzled how many treatments offered by naturopaths (like high dose intravenous vitamin C, “functional medicine, or various diagnostic tests like thermography) are any more “natural” than what “conventional medicine offers. What is really most attractive to patients is the claim that they can treat cancer without the toxicity associated with known effective treatments for cancer, such as radiation, surgery, and, most feared of all, chemotherapy. Unfortunately, when patients with highly treatable cancers believe these claims, the result can be fatal:

It is late July. An Auckland woman sits at her dining room table, frail, cosseted in a wool-knit beanie, brittle wisps of hair poking out.

She knows her time is running out. She doesn’t know it, but she will be dead in two weeks.

First, though, she wants to speak out to call for regulation of naturopaths after her bitter experience with alternative therapies.

“From my point of view the naturopath has used people like me as guinea pigs,” the Auckland woman told Stuff. “I don’t think naturopaths should try to heal cancer. I trusted in naturopathy, I don’t trust in it any more.”

This is the price patients with treatable cancers can end up paying for trusting naturopaths. This patient, who is not named in the story, didn’t even have cancer, but rather a premalignant condition known as ductal carcinoma in situ (DCIS). I’ve written about DCIS on multiple occasions , because it is a condition whose management is becoming less straightforward as we understand more about the biology of the disease. The reason is that not all DCIS progresses to life-threatening breast cancer in a woman’s lifetime; indeed, most probably do not, to the point where watchful waiting is being discussed as a viable treatment option for women with low grade, low risk DCIS. There is a clinical trial, the Low Risk DCIS (LORIS) trial, comparing outcomes between immediate surgery and active monitoring for low-risk DCIS. Close to 100% of women with DCIS women should survive their disease with treatment.

Here is this patient’s story. It began in 2013:

In July 2013 she had been diagnosed with ductal carcinoma in situ (DCIS), a pre-cancerous breast condition. Her oncologist told her she had a “50/50” likelihood of contracting breast cancer, and recommended an immediate double-mastectomy.

“I was shocked and scared of surgery, I’d never had surgery. Then you face one breast, both breasts, no breasts, you start looking for alternatives.”

Unaware some DCIS strains are more aggressive than others, she believed time was on her side and she could try alternative medicine.

We don’t have any information on the features of this woman’s DCIS that would allow me to estimate her risk. For instance, we don’t know from this story whether it was high or low grade, low grade being lower risk. We don’t know if it had high risk features, like comedo necrosis, which portends a high risk of progression to invasive cancer. I was also puzzled by the recommendation for immediate bilateral mastectomy. Mastectomy is usually not indicated for DCIS. Most DCIS lesions can be treated with breast conserving surgery (lumpectomy) followed by radiation. Mastectomy is reserved for cases of diffuse or extensive DCIS in which all the disease can’t be removed in by lumpectomy. Bilateral mastectomy is rarely indicated for DCIS, the main exception being when both breasts are involved with extensive DCIS, a very uncommon situation. In fairness, some women with extensive DCIS in one breast and DCIS in the other breast amenable to mastectomy will opt, not necessarily inappropriately, for bilateral mastectomy, but this is usually the woman’s choice, and this article states that the oncologist recommended bilateral mastectomy. Again, no reason for this recommendation is provided in this news story; so I don’t know whether this patient had any of the indications for a bilateral mastectomy in DCIS. I’d be willing to bet that she probably didn’t and that this recommendation was probably a recommendation for massive overtreatment.

I mention this because the aggressiveness of the recommended surgery almost certainly played a role in this Auckland woman’s disastrous decision. Whatever her reasons, though, this is how her story played out. The woman and her husband found a naturopath, whose name is never mentioned (much to my irritation), having heard stories about her alleged success rate and discovered that she was affiliated with Cape Town University. (Did they mean the University of Cape Town? I wondered.) The naturopath also advertised that she had an MDipNat.Herb from the South African College of Natural Medicines, which is apparently a degree in herbal medicine of some sort. This particular naturopath saw her and then followed up her treatments with Internet consultations:

The naturopath continued treating the Auckland woman over the internet using words such as “tumours” and “cancer”. “At this stage there is nothing to worry about,” she emailed.

Apart from a grueling regime of daily natural supplements, for a time the naturopath told her to simply apply ointment to her breasts.

The woman emailed the naturopath photos of her bruised breasts: “Hi, those green spots definitely little tumours,” the naturopath replied. “It looks like there is just the start of cancer, would most probably have developed into major pictures!!! … fantastic those come out”.

A week later the Auckland woman sent more pictures.

“Wow, girl this looks great,” the naturopath replied. “The top one looks at this stage there is nothing to worry about … you can just apply zambuck ointment to that to draw out the last anger and puss … do you have that, can I courier you some?”

Now here’s something I never figured out. Naturopaths contend that theirs is “natural medicine” that is much less toxic and causes many fewer side effects; sometimes it’s claimed that there will be no side effects. Yet their treatment regimens are often quite onerous. For example, read the description of this woman’s regimen, which got to the point where she had to get up earlier every morning just to “go through all my stuff.” She spent thousands on “myriad pills, drops, powders and ointments the naturopath advised her to take.” Then consider other alternative cancer treatments favored by naturopaths, like the Gerson protocol, which requires drinking thirteen organic juices (which have to be prepared fresh hourly) and well over a hundred supplement pills per day, as well as a basic organic whole food plant-based diet plus five coffee enemas per day. I kid you not.

In any case, none of her treatments worked, and in fact the woman became progressively fatigued to the point where she gave up less than a year later and gave the supplements back because she “didn’t believe in them any more.” Even so, instead of going back to real medicine, she went to another naturopath and didn’t finally undergo surgery until January 2016. One thing that bothers me about this story is that the timeline isn’t really very clear. As a cancer doctor, I really want to know when this patient was diagnosed with invasive cancer, as that would clarify my discussion a lot. However, I do know how the story ends, and it ends tragically:

Before dying, the woman confronted the naturopath by email about her treatment methods and unavailability.

And with days left to live, the Auckland woman asks one last time, “I don’t understand why there are no regulations?”

It’s late July. Pale, hunched, shuffling, months after her cancer had spread to her lymph nodes, the woman holds on.

“If we could make a difference there with regulation, that would help everyone – that would help the naturopath,” she says.

“I’m starting my chemotherapy, it’s quite exciting, the hope is it will shrink the existing cancer but it has spread, I don’t know how much hope there is.

“I don’t want to lose hope.”

It was not to be. This month, she passed away.

When the reporter, Simon Maude, contacts her one last time, instead of expressing regret, the naturopath makes it all about her:

And the naturopath? We give her a final phone call.

She’s closing her holistic health practice in September, she says.

“I’ve just had it. At the end of the day it’s a thankless job, I’ve given my life to people to try and help them, I’ve had enough”.

Selling ineffective supplements that fail to prevent what was almost certainly an eminently preventable death is a “thankless job.” I suppose so because this naturopath definitely doesn’t deserve anything resembling thanks. I did, of course, try to figure out who this naturopath is, and I think I did. Since I can’t be sure, I will not publish my speculation, however. Instead, I will move on to the second case.

Another way naturopaths harm cancer patients

The second patient, a 55-year-old woman named Jane Norcross-Wilkins, had breast cancer and treated by the same naturopath, but her case is quite different otherwise. She had breast cancer in 2001, but it recurred in 2011. By 2015 it was stage IV and incurable. As her husband, Mike Malcolm put it, she just wanted more time, with the rationale, “OK, if I can’t beat it, I can work with it and see how far I can go,” which is certainly not unreasonable and is the way many patients with terminal cancer think. It’s also the approach taken by real oncologists: To slow the progression of the cancer for as long as possible while also balancing the toxicities of therapy with the limited anticipated benefits and taking into account the patient’s values (e.g., to fight for as long as possible vs. to be as comfortable as possible for as long as possible). However, such decisions require a dispassionate assessment and communication of the actual prognosis versus the risks and toxicities of therapy. Naturopaths frequently short circuit that necessary discussion with false hope, as in the case of Norcross-Wilkins, who went to see this same naturopath in December 2015:

Upfront with the naturopath about Jane’s terminal cancer diagnosis, they listened as the naturopath held court. “She’s good at talking herself up, she highlighted how certain parts of the cancer process can be interrupted or changed with processes she used, stopped and reversed.

“You could listen to her all day, she’s very knowledgeable, she explains things in layman’s terms.”

Jane was put on a gruelling regime of expensive natural remedies. She discovered homeopathic melatonin sold to her for $50, retailed elsewhere for $12; vitamin C caplets sold for $140 retailed for $87 over the counter.

As with the first patient – not only was Norcross-Wilkins’ regimen expensive, it was brutal:

Mike explains: “It was like a detox, a purge, I’ve never seen anything like it, the amount of things she had to take. But the naturopath said ‘no, no Jane’s got to keep on doing it, it’s a little bit hard at the start but you’re killing the cancer, you’re giving the cancer an environment it can’t live in’.

“But Jane couldn’t live like that.”

As it became apparent that the woo wasn’t working, this happened, the naturopath became progressively more difficult to get a hold of, even after having promised at the beginning that Norcross-Wilkins could call her “any time.” Phone calls went unreturned, and e-mails were not answered for days. When Norcross-Wilkins was hospitalized for three weeks in January 2016 the naturopath didn’t inquire about her. The end result:

Angry emails sent to the naturopath ended with Jane and Mike dumping her late the following month.

A final March 2016 letter from Jane to the naturopath ended: “I strongly suggest you set up supervision for yourself and a highly experienced practitioner to ensure that you are working ethically … I also suggest you look into registering with a body such as the NZ Natural Health Council or the NZ Society of Naturopaths Inc.

“I do not wish to continue as your client,” Jane concluded.

The naturopath apologised profusely, and promised not to treat cancer sufferers any more. She refunded the cost of some of Jane’s medicine’s [sic].

Let’s just put it this way. Real oncologists don’t have the option, ethically, of avoiding their patients who aren’t doing well. In any event, Norcross-Wilkins married Malcolm in December 2016 and died on February 8, 2017.

Defenders of naturopaths and other quacks will frequently point to patients like Jane Norcross-Wilkins and ask, “What do they have to lose? Conventional medicine can’t save them.” The response is simple, if not easy. Patients like Norcross-Wilkins are going to die, but what naturopaths like this one rob them of are effective palliative care, so that they suffer more than they need to, both from their cancer progression and from the quack therapies they undergo; money that could go to their estate that instead is spent on ineffective nostrums; quality time with their families before their condition deteriorates too much; and a chance to put their affairs in order properly before the end.

The naturopath responds

There are usually at least two sides to every story, and this one is no exception. Unfortunately, the naturopath’s side of the story comes across as self-serving and very much covering her posterior:

“Cancer IS an exhausting disease,” the naturopath tells Stuff. “There’s no nice way to treat cancer, you show me a patient who is doing anything that is making them feel better.

“People think because [my treatment is natural] it should feel good. It’s not, there’s no easy way to treat cancer.”

Tumours, cancer – at this point shouldn’t the naturopath have stopped and suggested the woman go back to her oncologist?

“It’s not my place to refer them to a specialist,” she tells us. “I can’t do that because I’m a naturopath.”

That last bit strikes me a very intentionally legalistic justification. Let’s just put it this way. I don’t know the law in New Zealand, but whatever it says regarding regulating medical practice I’d be willing to bet that there’s nothing in it that forbids a naturopath from saying to a patient who is clearly not getting better, “I really think you should see an oncologist.”

Be that as it may, it turns out that naturopaths are not regulated in New Zealand. New Zealand Society of Naturopaths vice-president Sharon Erdrich is quoted as saying that New Zealand naturopaths want “tighter regulations.” This claim would seem to be belied by the fact reported that a non-regulated health profession can submit an application to the Ministry of Health to be regulated and the observation that the “ministry has not received an application from naturopaths to become regulated under the Health Practitioners Competence Assurance Act 2003.”

Beyond cancer and New Zealand

Of course, naturopaths are not just dangerous to cancer patients, as a recent story that I had thought about blogging about but somehow never got to shows. In this incident, which occurred two years ago, an Australian naturopath, using the rationale that a breastfeeding mother needed to “alkaline” her milk and “eliminate the toxins” from the baby’s body, recommended a 100% raw vegan diet:

An Australian naturopath who instructed a breastfeeding mother to stick to a “raw food” diet to cure her son’s eczema has admitted that her advice endangered the baby’s life.

Marilyn Bodnar, 61, was accused of directing the mother, a midwife who cannot be named for legal reasons, to abandon other medical advice and adhere to a strict diet of raw vegetables, fruit and seeds.

By the time the mother took the baby to hospital, he was limp, had sunken eyes and police believe he was just days from death.

According to court documents, Bodnar, from Sydney’s south-west, made the mother feel guilty for eating “rubbish” during her pregnancy and using steroid creams for the boy’s eczema.

When the baby developed a fever, this naturopath’s irresponsible advice went even beyond this. She advised the mother to drink nothing but water, saying, “You’re not allowed to drink anything if you want to see him better.” When the infant started vomiting, the naturopath went beyond even that and told the mother to continue, saying, “increased temperature meant increased vitality.” By the time the baby was taken to the hospital, he was badly emaciated and, at eight months, weighed only 6.39 kg, which placed him in the zero percentile for babies his age.

It can now be revealed that Bodnar — who boasts online of being able to help “parents and children’s health and infertility” — faced a manslaughter trial in 1988 over the death of a woman who was on a water only diet for 63 days.
Bodnar was acquitted of the manslaughter of 42-year-old Narelle Niemann, who lost 35 per cent of her body weight while she was under Bodnar’s care.
Prosecutors argued Bodnar failed to get professional help when her condition deteriorated, but the jury found her not guilty. She argued at trial she was helping Ms Niemann as a friend and not as a patient.

So Bodnar’s been at this sort of thing for nearly 30 years at least? One wonders why Australian authorities couldn’t stop her until now. Not that we in the US have anything to brag about on the score of stopping naturopathic quacks from endangering lives. For instance, four months ago, I wrote about the case of Jade Erick, a young woman with eczema who died of a hypersensitivity reaction when a naturopath named Kim Kelly treated her in his office with intravenous curcumin.

Another case that I’ve discussed here before involved a woman in Bowling Green named Fikreta Ibrisevic who sought the services of a local naturopath named Juan Sanchez Gonzalez to treat her rhabdomyosarcoma and was quoted in news reports as having told her and her husband Omer Ahmetovic that “chemotherapy is for losers” and that he could “guarantee” that Ibrisevic would be cancer-free with his treatments within three months. Predictably and tragically, Gonzalez’s quackery didn’t work. Ibrisevic also sought out the care of other naturopaths. Unfortunately, by the time Ibrisevic realized this and sought out conventional medical care it was too late for her. Although she accepted chemotherapy, the cancer was too advanced. She died of it on February 27, 2017. This case is compounded by further tragedy, as well. On a Friday evening after office hours four days after his wife’s death, the grieving husband allegedly walked into Gonzalez’s office and shot him dead.

There are no “good naturopaths”

I started this article by complaining about the SIO, which will no doubt consider my mentioning of the organization unfair in relationship to discussing these cases of naturopaths leading to the deaths of cancer patients. The reason is that most of the naturopaths I just discussed were not licensed and didn’t come from “approved” schools. To some extent, there might be a reasonable point there, but only in that naturopaths who join SIO are usually associated with academia, which (usually) keeps their worst impulses under control. Usually. Unfortunately, though, organizations like the SIO, as well as most integrative medicine physicians, turn a blind eye to the quackery inherent in naturopathy. To illustrate this, I like to relate an anecdote. (You can skip the next paragraph if you’ve heard it before, as I do repeat it from time to time.)

Back when I published my Perspective article, “Integrative oncology: Really the best of both worlds?” in Nature Reviews Medicine three years ago, the SIO immediately criticized me for spending so much of it discussing homeopathy, which its leadership properly rejected as being pseudoscience. There were two aspects of this complaint that amused me. First, homeopathy was a far smaller part of the first draft of the article, but reviewers forced me to add more. Second, even more amusing (or disappointing—or both) was that it was clear that the SIO had no clue how integral homeopathy is to naturopathy. I responded by pointing out that naturopathy schools include many hours of homeopathy in their curricula and that naturopaths are tested on homeopathy in the NPLEX, the licensing examination used by states that license naturopaths. I also couldn’t resist twisting the knife a little bit by pointing out that one of the authors of the SIO clinical guidelines for breast cancer was a naturopath who at the time had an open clinical trial of homeopathy listed on ClinicalTrials.gov. Basically, you can’t have naturopathy without homeopathy. To reject homeopathy as pseudoscience but still accept naturopaths as co-equal medical colleagues is inherently contradictory, because all naturopaths are trained in homeopathy and most of them use it.

Consider, for example, Kim Kelly, the “naturopathic physician” whose irresponsible use of an unproven treatment like IV curcumin for eczema killed Jade Erick. He graduated from Bastyr University, basically the Harvard or Yale of naturopathy schools, the crème de la crème of naturopathy schools. (Never mind that being the crème de la crème of quack schools is not a good thing.) Any naturopath who looked at his credentials would tell you that he is everything that a good, well-trained naturopath should be, and he is fully licensed by the State of California to practice naturopathy. Yet, as I discussed before, this upstanding naturopath offered a veritable cornucopia of quackery: biopuncture (an unholy union of homeopathy and acupuncture), naturopathic detoxing, hormonal balance treatment, intravenous nutrition, intravenous vitamin C, a dangerous modality like intravenous peroxide, and various “wellness programs.”

Let’s just put it this way. I’ve examined the practices of many naturopaths in my time. Outside the very privileged, cloistered, and protected ivory towers of medical academia, I’ve been unable to find any detectable difference between the level of quackery offered by the great unwashed unlicensed mass of naturopaths who didn’t graduate from schools like Bastyr and the elite group of naturopaths (elite only among naturopaths, that is) who did go to “accredited” naturopathy schools and are licensed. Yes, I acknowledge that I haven’t done a systematic study and my views might be affected by confirmation bias, but even if that’s true I’ve found a whole lot of what naturopaths would consider their crème de la crème offering a whole lot of quackery and discussing it in private forums, including some faculty of naturopathy schools and leaders of organized naturopathy, again the crème de la crème.

I tend to focus on cancer when I discuss the quackery in naturopathy because I’m a cancer surgeon. As a cancer doctor, I recognize that naturopaths are dangerous and harmful to cancer patients. No, strike that. They are dangerous and harmful to all patients.